Membership application – Broken Rites

All information given on this form will be treated in confidence within Broken Rites.

Title (Optional)

Full Name*

Address*

Street Address Address Line 2 City County Post Code

Phone Number*

Alternative Phone Number

Email*

Date of Birth

DD slash MM slash YYYY

Are you separated or divorced from an ordained Christian Minister?*

Year of marriage/partnership breakdown*

Denomination of spouse / partner from whom you are separated / divorced*

C of E, URC, Methodist etc

Diocese / area where you were living at time of marriage / partnership breakdown*

How did you hear of Broken Rites?*

Someone who knew my circumstances told me about it

Facebook

Twitter

Church or friend from church

Church Times

Other newspaper

Radio or TV

Other

Are you in contact with your Bishop's Visitor or other support from your denomination beyond the local church?*

Yes

Our Membership Secretary will be in touch about admin matters. Would you like someone else to contact you as soon as possible to talk about your circumstances?*

By phone call

By text

By e-mail

On Messenger

Not now but maybe in future: I will inform Broken Rites when/if this is the case

Would you like to join our confidential group on Facebook?*

Yes

Maybe

Are you willing for these details to be shared with membership reps and links within Broken Rites so they can support you?*

Yes

Maybe in future after further discussion

Are you willing for these details to be shared with other members in your region, for mutual support?*

Yes

Maybe in future after further discussion

Annual subscription

First year membership is free. Thereafter, annual subscription is £15 or, in case of hardship, not less than £2.

Online payment – when required – should be made to: Sort code 60-22-45 Account 72017325 (ensure your name is shown as reference)

Rite Lines

Our twice yearly newsletter can be received in booklet form by e-mail or post.

Email is our default method of distribution of our twice-yearly newsletter Rite Lines, Annual Report and other occasional communications. If you cannot access e-mail communications and require a printed copy please tick box below*

e-mail (PDF) is fine

post please

Is there anything else you would like us to know, or anything in your answers above you wish to clarify?

Do you consent to the Broken Rites Membership Secretary retaining this information in accordance with our Privacy Policy?*

Yes

Any questions? Contact: membership@brokenrites.org
Please update us if/when any of your contact information changes, so we can keep in touch. Thank you!

apply for

Membership

Annual subscription

Rite Lines